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The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting. Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed.
This step-by-step guide takes the reader through the complex process of investigating serious incidents in health, social care, and criminal justice environments, acknowledging differences of culture and context that shape an investigation. Taking a multi-disciplinary approach, Part 1 begins by exploring the key principles of investigation, including ethical and legal perspectives, the involvement of families and carers, and being aware of unconscious bias, among other issues. Part 2 outlines in detail the conduct of investigations, from planning to processing the findings, before moving on to Part 3, carrying them out in diverse settings. Further chapters then look at investigating within diverse environments before moving on to to Part 4 which deals with reviewing and analysing the evidence collected and writing up the investigation. This final part also examines the pivotal issue of learning from the investigation and disseminating the report. The inclusion of case studies, models of good practice, and vignettes enables the reader to view each stage of the process in context and drive the transformation of practice. This practical resource is designed to support health and social care professionals who undertake investigations as part of their role, including nurses, allied health practitioners, social workers, doctors, and psychologists, as well as military personnel and law enforcers. It is an essential companion.
v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.
"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
World Patient Safety Day is observed on 17 September each year with the objectives of increasing public awareness and engagement, enhancing global understanding, and spurring global solidarity and action to promote patient safety. Each year a campaign is launched on a selected patient safety-related theme. The overall goal of World Patient Safety Day is to improve globally patient safety at the point of care. To support this endeavour, World Patient Safety Day goals are released every year. The goals aim to achieve tangible and measurable improvements at the point of health service delivery. Each goal is accompanied by suggested actions based on existing WHO guidance, which could facilitate improvement in the focused safety practice domain. Links to available WHO resources on the subject are provided with each goal. The World Patient Safety Day goals 2021–2022 are aimed at making maternal and newborn care safer. Target audiences are; health care facilities and health service providers, point of care health workers, patient groups, professional associations, policy makers, health administrators.
At a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
This book explores how concerns can be raised about the NHS, why raising concerns hasn't always improved standards, and how a no-fault open culture approach could drive improvements. The book describes a wide range of mechanisms for raising concerns about the NHS, including complaints, the ombudsman, litigation, HSIB, and the major inquiries since 2000, across the various UK jurisdictions. The NHS approach is contextualised within the broader societal developments in dispute resolution, accountability, and regulation. The authors take a holistic view, and outline practical solutions for reforming how the NHS responds to problems. These should improve the situation for those raising concerns and for those working within the NHS, as well as providing cost savings. The no-fault approaches proposed in the book provide long-term sustainable solutions to systemic problems, which are particularly timely given the impact of the COVID-19 pandemic on the NHS. The book will be of interest to academics, researchers, ADR practitioners, practising lawyers, and policy makers.
A Clinician's Survival Guide to District Nursing covers the specialist skills and knowledge nurses need to join the rapidly expanding, increasingly important community nursing workforce. The book is a quick reference guide designed to support autonomous decision making amid the wide range of conditions district nurses are expected to manage, recognising and highlighting the advanced skills of district nurses. It will help the reader understand what it means to work in the community, acquire the fundamental knowledge of clinical skills necessary to ensure best practice, and explore ways of working to ensure optimal care delivery through joined-up health and social services. Written by specialists in community nursing, this indispensable new book is ideal for students exploring district nursing as a career option, as well as nurses transitioning to a district nursing team role. - Covers important issues including leadership, quality improvement and the integrated care system - Up-to-date and contemporary - incorporates changes to clinical care and management, including the impact of COVID-19 - Clear, concise and easy to follow - Bullet points and diagrams make it easy to understand difficult concepts - Reflective activities reinforce learning - Case studies highlight best practice - Complements university programmes focusing on community servicesThe Clinician's Survival Guide series (formerly A Nurse's Survival Guide) brings you concise, accessible content, prepared by experts in a handy quick-reference format.
This book introduces the core knowledge and skills for comprehensive risk assessment and management in healthcare settings and applies relevant ethical and legal principles. It emphasises that patient safety requires a holistic and inclusive approach to maximise patient wellbeing in a diverse population with known health inequalities. Exploring the concept of ‘avoidable risks’ which may be posed to the health and wellbeing of individuals, the public and communities within a given healthcare context, this book explores potential system failures and human factors, while providing an insight into the significance of the relationship between a culture of care and patient safety. It includes chapters on the ethical and legal framework related to patient safety, the equality, diversity and inclusion context, advocacy and empowerment, risk, and human factors as well as accountability and harm. Notably, there is also a focus on two in-depth chapters which explore patient safety in relation to medication management and end-of-life care. Throughout the book, there are numerous reflection points, examples of case law and illustrative case studies and thinking points to help the reader apply key principles to aid their learning and think critically. Patient Safety in Clinical Practice offers a fresh insight into the link between patient safety and holistic care. It is aimed at nursing and allied health students and professionals, particularly those undertaking study related to assessing and planning care, as well as law, ethics and professional issues.